Every finding on record at Rivers Edge Rehabilitation and Healthcare Center

Based on observation, interview, and facility policy review, the facility failed to store food in a sanitary manner. Specifically, the facility failed to ensure refrigerators were clean, and food items were labeled and dated prior to storage in a nutrition refrigerator located at the nurse's station. These failures had the potential to affect all residents who received meals and snacks from the facility. The findings included:Review of facility policy, Monitoring of Cooler/Freezer Temperature, revised 09/01/2024, indicated, It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. This policy also addresses refrigerated storage. The policy further indicated, 1. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. a. Temperatures will be checked and logged at least twice per day by designated personnel. The policy continued, 11. Refrigerated food shall be labeled, dated, and monitored so that is issued by the use by date, frozen, or discarded, whichever is applicable. Review of facility policy, Sanitation Inspection, revised 09/01/2024, indicated, It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. The policy continued, 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. The policy continued, 4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations.5. Inspections will be conducted but not limited to the following areas: a. Dry storage b. Freezer c. Refrigerator d. Dish room e. Pot wash f. Main production area g. Food preparation area h. General dietary observations. During an observation of the kitchen and concurrent interview on 03/09/2026 at 9:12 AM, the kitchen's walk-in refrigerator was observed to have a thick black and gray matter build-up around the ceiling inside the refrigerator radiating out from the dual fans. The Dietary Manager (DM) stated that the black and gray matter build-up was dust and that the refrigerator should have been cleaned weekly. During an observation on 03/11/2026 at 3:41 PM, the nutrition refrigerator revealed a temperature log that was missing temperatures for 03/10/2026 and there were no temperature measurements for the freezer compartment. Inside the freezer compartment there was a frozen, sticky, tan residue and ice packs in plastic bags were stuck to the surface inside the freezer compartment. There were two 48 fluid ounce (a unit of measure) tubs of rainbow sherbet, a popsicle box, and a bag of popsicles that were unlabeled and undated. During an interview on 03/13/2026 at 10:10 AM, the Maintenance Director (Maint. Dir.) stated housekeeping was responsible for cleaning the nutrition refrigerator weekly on Thursdays. The Maint. Dir. stated that the kitchen and nursing staff were responsible for logging temperatures. During an interview on 03/13/2026 at 11:23 AM, Licensed Practical Nurse (LPN) #3 stated housekeeping was responsible for cleaning the nutrition refrigerator every Thursday. LPN #3 stated temperature logs should have been updated, and any food items inside the nutrition refrigerator should have been labeled with names and dates. LPN #3 stated food items without labels were discarded. LPN #3 stated it was important to keep the nutrition refrigerator clean, and the temperature monitored and logged daily to ensure residents did not get sick from spoiled foods. During an interview on 03/11/2026 at 3:51 PM, the DM stated she was responsible for recording and updating the temperature logs and that she did not record the temperature on 03/10/2026. The DM stated foods inside the refrigerator and the freezer compartment should have been labeled with names and dates or should have been discarded if they were not labeled. During an interview on 03/13/2026 at 8:39 AM, the Director of Nursing (DON) stated kitchen staff were responsible for cleaning the kitchen refrigerator, and housekeeping was responsible for cleaning the nutrition refrigerator. The DON stated she expected the refrigerators to be cleaned weekly and temperature logs to be taken and updated daily for all refrigerator compartments. The DON stated it was important to keep the refrigerator and freezer compartment clean, and temperatures monitored, so food did not spoil and potentially cause harm to the residents. During an interview on 03/13/2026 at 9:04 AM, the Administrator stated all refrigerators should have been cleaned. The Administrator stated housekeeping was responsible for cleaning the nutrition refrigerator, and kitchen staff were responsible for the kitchen refrigerator. The Administrator further stated she expected temperatures to be taken daily for the refrigerator and freezer compartments. The Administrator continued, stating it was important to keep refrigerators and freezers clean, and temperature logs updated to ensure food did not pose a risk for bacterial growth. Additionally, the Administrator stated that food stored inside the refrigerator should have been labeled.

Based on interview, record review, and facility policy review the facility failed to develop a care plan to address the tracheostomy (an opening in the neck to facilitate breathing) care for 1 (Resident #5) of 1 sampled residents reviewed for respiratory care. The findings included: Review of the facility's undated policy titled, Comprehensive Care Plans, indicated, It is the policy of this facility to develop and implement a comprehensive-person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy further indicated, 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. and 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Review of facility policy, Tracheostomy Care, reviewed 12/31/2024, indicated, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards or practice, the comprehensive person-centered care plan and resident goals and preferences. The policy further continued, 4. Based upon the resident assessment, attending physician's orders, and professional standards of practice, the facility in collaboration with the resident/resident's representative will develop a care plan that includes appropriate interventions for respiratory care. Review of the facility's admission Record indicated the facility admitted Resident (R) #5 on 01/12/2026. According to the admission Record the resident had a medical history that included diagnoses of cerebral infarction (stroke) due to thrombosis (blood clot) of unspecified cerebral artery, chronic obstructive pulmonary disease (a lung condition that makes it hard to breath), chronic respiratory failure with hypoxia (low oxygen levels), and tracheostomy status. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/18/2026, revealed the facility assess Resident #5 with a Brief Interview for Medical Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed that the Resident received respiratory treatments that included oxygen therapy, suctioning, and tracheostomy care while a resident and within the last 14 days of the assessment period. Review of the facility's Care Plan Report, for R5 included a focus area initiated 01/25/2026 that indicated the resident had difficulty in communication related to the resident's tracheostomy. Interventions directed staff to allow the resident adequate time to respond and repeat as necessary, to face the resident and make eye contact, use simple, brief, consistent words, and use alternative communication tools as needed. There was no focus area that addressed the resident's tracheostomy care or respiratory services. Review of Resident #5's Order Summary Report, with active orders as of 03/10/2026, contained an order dated 01/22/2026 to cleanse tracheostomy site and perform tracheostomy care every shift. During an interview on 03/13/2026 PM at 2:14 PM, Licensed Practical Nurse (LPN) #2 stated that the MDS nurse was responsible for updating residents' care plans. LPN #2 stated she did not see a care plan specifically addressing Resident #5's tracheostomy, and that a care plan was essential to ensure nursing staff were informed on proper tracheostomy care and remained current with prescribed interventions. During an interview on 03/13/2026 at 11:07 AM, the Director of Nursing (DON) stated Resident #5 did not have a care plan specifically for tracheostomy and that her expectation was that Resident #5's care plan address the tracheostomy. The DON further stated that care plans were essential, as their absence could impact the quality and consistency of care provided and fail to guide staff in the proper management of the tracheostomy. During a subsequent interview on 03/13/2026 at 2:50 PM, the DON stated that Resident #5 should have had a care plan that was specific for the tracheostomy, containing the size of the tracheostomy, oxygen flow rates, and specific care required for the tracheostomy. During an interview on 03/13/2026 at 9:29 AM, the Administrator stated care plans should have been done appropriately for Resident #5.

Based on observation, interview, record review, and facility document and policy review, the facility failed to maintain infection control practices during tracheostomy care for 1 (Resident #5) of 1 resident observed during tracheostomy care. Specifically, staff failed to maintain a sterile field and use proper hand hygiene during tracheostomy care. The findings included: Review of facility policy titled, Tracheostomy Care, dated 12/31/2024, indicated, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences, The Policy further indicated, 6. Procedure with Use of Reusable Cannula: a. Explain the procedure to the resident and screen for privacy. b. Perform hand hygiene per facility policy. c. Put exam gloves on both hands; masks and eye wear should be worn if there is a likelihood of splashes and splattering. d. Suction tracheostomy per facility policy. e. Remove old dressing; pull soiled glove down over the hand, and the soiled dressing, and roll the glove over dressing; Discard both in appropriate receptacle. Perform hand hygiene. f. Prepare equipment on bedside table. g. Open and set up the sterile tracheostomy care kit and apply sterile gloves. n. Dispose of equipment and perform hand hygiene Review of a facility policy titled, Hand Hygiene, dated 09/01/2024, indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The policy further indicated, 6. Additional considerations: - a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility's undated policy, Tracheostomy Care packet, indicated, Tracheostomy Suctioning Procedure, that included, 2. Wash hands and don gloves and other PPE. The education packet continued, 7. Open sterile suction kit and fill container with saline. Be sure to set up sterile container touching only the outside surface. 8. Put on sterile gloves. The dominant hand remains sterile and the non-dominant hand is nonsterile. Review of the facility document, admission Record indicated the facility admitted Resident #5 on 01/12/2026. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke) due to thrombosis (blood clot) of unspecified cerebral artery, chronic obstructive pulmonary disease (a lung condition that makes it hard to breath), chronic respiratory failure with hypoxia (low oxygen levels), and tracheostomy status. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/18/2026, revealed the resident received respiratory treatments that included oxygen therapy, suctioning, and tracheostomy care while a resident and within the last 14 days of the assessment period. Review of the facility's Care Plan Report, for Resident (R) #5 included a focus area initiated 01/25/2026 that indicated the resident had difficulty in communication related to the resident's tracheostomy. Interventions directed staff to allow the resident adequate time to respond and repeat as necessary, to face the resident and make eye contact, use simple, brief, consistent words, and use alternative communication tools as needed. There was no focus area that addressed the resident's tracheostomy care or respiratory services. Review of Resident #5's Order Summary Report, with active orders as of 03/10/2026, contained an order dated 01/22/2026 to cleanse tracheostomy site and perform tracheostomy care every shift. During an observation on 03/10/2026 at 11:08 AM, Licensed Practical Nurse (LPN) #2 entered Resident #5's room to perform tracheostomy care. LPN #2 set up a sterile field and prepared suctioning supplies. LPN #2 picked up a sterile glove with her bare hands from the sterile field; she then returned the sterile glove back onto the sterile field, stating she had to go obtain another sterile glove as there was only one. LPN #2 left the resident's room, returned, did not perform hand hygiene, applied sterile gloves, donned (put on) a gown, and performed suctioning of Resident #5's tracheostomy. LPN #2 then threw away the used supplies, doffed (removed) the gown and gloves, and performed hand hygiene. LPN #2 donned a new gown (but did not tie the neck and waist tie strings), donned gloves, set up a new sterile field, and opened the new cannula and collar supplies. As LPN #2 opened the sterile supplies and dropped them onto the sterile field, LPN #2's loose gown was observed touching the sterile field. LPN #2 then reached behind her neck and back, tied the gown's neck and waist tie strings, and continued opening the sterile supplies without performing hand hygiene. During an interview on 03/10/2026 at 11:50 AM, LPN #2 stated that a sterile field was an area where there were no infectious organisms that could cause infections. LPN #2 stated nothing was to touch the sterile field except sterile supplies. LPN #2 stated she contaminated the sterile field when she did not wash her hands, picked up the sterile glove and put it back down onto the sterile field, and when her untied gown came into contact with the sterile field. During an interview on 03/12/2026 at 10:05 AM, the Infection Prevention (IP) nurse stated that sterile technique was important to prevent the introduction of microorganisms to a resident. The IP nurse stated that tracheostomy care was a sterile procedure, and LPN #2 did not follow sterile technique. During an interview on 03/12/2026 at 11:00 AM, the Director of Nursing (DON) stated that tracheostomy care was a sterile procedure and said that LPN #2 should have started a new sterile field when she contaminated the original sterile field. During an interview on 03/12/2026 at 11:35 AM, the Administrator stated it was important to follow sterile technique during tracheostomy care.

Based on observation, interview, and review of facility policy, it was determined the facility failed to store drugs in accordance with currently accepted professional principles for one (1) of two (2) medication carts audited out of a total of four (4) medication carts. Observation on 11/14/2024 at 11:45 AM, of the East Wing Medication cart revealed 17 cards of medications stored beyond the expiration date printed on the package labels for ten (10) of 20 residents (Resident (R) 60 (R60), R54, R69, R42, R61, R39, R86, R32, R36, and R65). The findings include: Review of the facility policies titled Medication Storage version 09/2020 and Medication Administration version 09/2020, were revealed no guidelines specified regarding the expiration dates of medications. Review of the Food and Drug Administration (FDA) website (fda.gov) with the current content date of 10/22/2022 revealed Drug Expiration dates reflect the time period which the product is known to be stable, which means it retains its strength, quality, and purity when it is stored according to its label conditions. Observation of the East Wing Medication Cart on 11/14/2024 at 11:45 AM revealed 17 cards of medications beyond the expiration date printed on the label affixed to the medication card. The prescribed medications to R60, R54, R42, R61, R39, R86, R65, R69, R36, and R32 included the following: R 60 - Compazine 50 mg tablets, a medication used for controlling nausea, expired 4/05/2024 with 10 tablets remaining; R54 - Zofran 4 mg tablets, a medication used for controlling nausea, expired 12/15/2023 with two (2) tablets remaining; Tylenol 325 mg tablets, a medication used to control pain and fever, expired 9/01/2024 with 10 tablets remaining; Tylenol 325 mg tablets expired 7/12/2024 with 18 tablets remaining; R69 - Tylenol 325 mg tablets expired 9/01/2024 with 16 tablets remaining; R42 - Tylenol 325 mg tablets expired 09/01/2024 with 13 tablets remaining; Tylenol 325 mg tablets expired 09/01/2024 with 26 tablets remaining; R61 - Zofran 4 mg tablets expired 6/08/2024, with six (6) tablets remaining; Tylenol 325 mg tablets expired 7/12/2024 with four (4) doses remaining; R39 - Bisacodyl 5 mg tablets, a medication used for constipation, expired 9/21/2024 with 13 tablets remaining; R86 - Tylenol 325 mg tablets expired 9/21/2024 with seven (7) tablets remaining; R65 - Tylenol 325 mg tablets expired 7/12/2024 with 10 tablets remaining; Zofran 4 mg tablets expired 5/23/2024 with 13 tablets remaining; Zofran 4 mg tablets expired 1/13/2024 with 14 tablets remaining; R36 - Tylenol 325 mg tablets expired 10/19/2024 with seven (7) tablets remaining; R32 - Tylenol 325 mg tablets expired 4/27/2024 with eight (8) tablets remaining; Tylenol 325 mg tablets expired 4/27/2024 with 10 tablets remaining. In an interview with Licensed Practical Nurse (LPN) #2 (LPN2) on 11/14/2024 at 12:30 PM, LPN2 stated each nurse was responsible to check the medication cart for expired medications. LPN2 stated that if she found an expired medication while passing medications, she would remove the medication from the cart and notify the pharmacy so a replacement would be sent. In an interview with the Unit Manager (UM) on 11/15/2024 at 10:04 AM, the UM stated the nurses are supposed to check medications daily and then monthly; and those checks were part of the facility's Quality Assurance Performance Improvement (QAPI). The UM further stated a pharmacy representative visited onsite monthly and followed staff as the nurse administered medications. The UM stated it was her expectation there were no expired medications on the medication cart. UM stated, I doubt there would have been an adverse reaction but there could have been. In an interview with the Director of Nursing (DON) on 11/15/2024 at 3:05 PM, the DON stated nurses were ultimately responsible to check the medication carts for expiration dates on medications. The DON went on to say that a liaison comes from the pharmacy monthly to observe medication pass and will audit medication carts for expiration dates, alternating carts that are checked. The DON stated there was a risk of an adverse reaction if a medication was administered past the expiration date and that it was her expectation the nurses checked the medication carts for expired medications, including PRN, unscheduled medications given as needed, medications. In an interview with the Administrator on 11/15/2024 at 3:25 PM, the Administrator stated it would be her expectation the medication carts were checked for expired medications and were removed from the cart if they were expired. She would expect nursing to contact the pharmacy for a replacement. She stated if an expired medication were administered, the pharmacy could be contacted to ask what potential negative outcome may occur then the physician would be notified to see if there would be any contraindications to them receiving an expired medication.

Based on observation, interview, and review of facility policies, the facility failed to ensure staff labeled and dated food items stored in the refrigerator and food items stored in dry storage. This deficient practice has the potential to affect all residents who utilize the facility's dining services. The findings include: Review of the facility's policy, Food Storage, revised 01/23/2018, revealed all incoming foods will have a delivery date and an open date or use by date. When the foods are stored in a container other than the original container, the container will be labeled with the name of the product and an incoming wash and fill date. Further review revealed the first in, first out method will be used in all storage. New product will be stored behind the old product. Review of document labeled, Job Title: Dietary Aide, dated 07/2016 revealed major duties and responsibilities included to prepare food in accordance with sanitary regulations as well as our established policies and procedures; assist in inventorying, rotating, and storing incoming food, supplies, etc. as necessary; and assure that dietary procedures were followed in accordance with established policies. Review of document labeled, Job Title: Cook, dated 07/2016 revealed major duties and responsibilities included to prepare food in accordance with sanitary regulations as well as our established policies and procedures; assist in inventorying, rotating, and storing incoming food, supplies, etc. as necessary; and cover, label, date leftovers, storing properly. Review of document labeled, Food Service Manager, dated 07/2016 revealed major duties and responsibilities included to plan, develop, implement, evaluate, and direct the Dietary Department, its programs and activities (includes department policies and procedures, job descriptions, etc.); develop and maintain dietary objectives and standards; assure department personnel follow established dietary policies and procedures; inspect the dietary area and practices for compliance with current applicable regulations regularly; assume the authority, responsibility, and accountability of directing the food service department; and assure that food storage areas are clean and properly arranged. Observation of the walk-in refrigerator on 11/12/2024 at 10:20 AM revealed one opened, undated bag of sliced white onions that were soft and starting to yellow; one opened, undated plastic container of chicken salad; one opened, undated bag of sliced white cheese; one opened, uncovered, and undated bag of lunch meat; one opened, undated bag of sliced bologna; one opened, undated plastic tub of cheese spread; one opened, undated plastic tub of jelly; two opened, undated one gallon jugs of barbecue sauce; one opened, undated one gallon jug of picante sauce; one undated bag of ready to eat salad that contained brown lettuce. Observation of dry storage food items on 11/12/2024 at 10:46 AM revealed six large bags of tortilla chips with an expiration date of 08/2024; one bag of opened, unsealed, undated spaghetti noodles; one sleeve of opened, undated Ritz crackers. Further observation revealed bulk storage of flour and panko breadcrumbs in separate bins that were not completely covered due to broken lids. In an interview with the Dietary Manger during these observations, she stated it was each kitchen staff member's responsibility to ensure food items were labeled and dated when opened. The Dietary Manger stated before kitchen staff worked, they received safe care service training on food safety. She further stated unlabeled opened food should be discarded because of the potential for food borne illnesses. In an interview with Dietary Aide (DA) 1 on 11/15/2024 at 1:14 PM, she stated when food was delivered, the dietary staff member that removed it from the truck was responsible to make sure it was dated. She further stated if she found food on the shelf that was not labeled or dated, she asked other staff, but if she did not know for sure she threw it away. DA1 stated a potential outcome for a resident that consumed outdated food included sickness or infection like E. coli or salmonella. In an interview with Cook1 on 11/15/2024 at 1:27 PM he stated all dietary staff were responsible for ensuring incoming food items were labeled and dated. He further stated the staff that received the stock were primarily responsible to label and date. Cook1 stated residents could potentially become sick if food items were not properly labeled and dated. He further stated if he observed open undated food in the kitchen, it was discarded and not served to residents. In an interview with the Dietary Manger on 11/15/2024 at 1:32 PM, she stated when deliveries were received, the boxes were immediately dated and inspected for damaged items. She further stated when food items were opened, they were supposed to be dated, but sometimes staff forgot. The Dietary Manger stated if undated items were not discarded and later fed to a resident, the resident was susceptible to food poisoning. She further stated if bulk food items such as sugar or breadcrumbs were left uncovered, they were subject to contamination which was also caused sickness. In an interview with the Administrator on 11/15/2024 at 3:22 PM, she stated there were not recent or current performance improvement plans related to food storage. The Administrator stated the Dietary Manager was responsible for dietary staff's compliance about dated, covered, and discarded food items. She further stated the Dietary Manager performed a monthly kitchen quality reviewed that was discussed in Quality Assurance Performance Improvement (QAPI) meetings. The Administrator stated she was in the kitchen at least quarterly and had not observed outdated, uncovered, or unlabeled food items. Additionally, the Administrator stated it was important food items were labeled and dated so residents were not served spoiled food, but rather received quality food. 51327

Based on observation, interview and review of facility policy, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections while providing wound care for 2 of 3 residents with wounds of the 23 residents sampled (Resident (R) 12 and R343). Observation of the Treatment Nurse/Licensed Practical Nurse (LPN) 1 performing wound care revealed the nurse did not perform hand hygiene after entering the residents' room before initiating wound care and did not change non-sterile gloves or perform hand hygiene after the gloves were potentially contaminated during the dressing change procedure. The findings include: Review of the facility policy, Handwashing Policy dated 04/2023 stated personnel are required to wash their hands after each direct or indirect resident contact for which handwashing is indicated by acceptable standards of practice. Ongoing review of the policy identified before and after touching wounds. Review of the facility policy, Dressings-Clean with a revision date of April 2023 stated in order to provide dressing changes with clean technique, the gloves were to be removed and the hands were to be washed after removing the old dressing before donning clean gloves and applying a clean dressing. Observation of wound care of a right buttock wound for R12 on 11/14/2024 at 9:42 AM with Treatment Nurse/LPN1 revealed the Treatment Nurse entered the room and stated I just washed my hands and proceeded don PPE that included a gown and non-sterile gloves. Treatment Nurse/LPN1 then brought the pre-set over-the-bed table to the right side of the bed. Wound care supplies were laid out a wax paper barrier and covered with wax paper. Wearing the clean non-sterile gloves, the Treatment Nurse/LPN1 removed the wax paper from the supply table and then began to remove the sheet and blanket that covered the resident. With assistance she positioned the resident onto the left side and pulled back the brief to expose the skin of the buttock. Without changing the gloves or performing hand hygiene, the treatment nurse proceeded to use a clean gauze from the supply table, moistened with saline and cleansed the wound then used a clean tongue depressor to apply a light layer of ointment to the wound bed. Then, without changing the gloves or performing hand hygiene, she covered the wound with a bordered foam dressing and positioned the resident onto the left side with a pillow support to the lower back. Observation on 11/14/2024 at 10:33 AM, revealed LPN1 performed a dressing change for R343's sacral pressure injuries. Continued observation revealed LPN1 did not wash her hands when she entered the resident's room. While wearing a pair of non-sterile gloves, LPN1 pulled back R343's covers, opened the resident's brief, and began touching his/her wounds. Additionally, LP1 take removed the paper covering the field of dressing change supplies and placed it into an empty garbage can. She then opened dressing packages with that same pair of non-sterile gloves on. LPN1 next changed her non-sterile gloves but did not perform hand hygiene between changing gloves. LPN1 took off the previous dressings, opened a tube of ointment, and applied the ointment with a tongue depressor to the open areas of the wound, all while wearing the same pair of non-sterile gloves. Furthermore, LPN1 did not perform hand hygiene when finished with the dressing change. In an interview with the Quality Assurance/Quality Improvement Nurse on 11/14/2024 at 3:55 PM they stated handwashing was done so that contamination does not occur. In an interview with the Director of Nursing (DON) on 11/14/2024 at 3:10 PM, the DON stated she expected staff to wash their hands before, during, and after wound care as well as change their gloves during wound care to reduce the potential for infection and contamination. In interview with the Administrator on 11/14/2024 at 3:25 PM, the Administrator stated it was her expectation that hand washing was performed before wound care and depending on if both hands were soiled during wound care, she would expect gloves to be clean in any aspect. The Administrator stated there could be infection control issues when providing wound care. 51281

Based on record review and interview the facility failed to provide residents and/or their representatives the right to formulate an advance directive for 1 of 9 sampled residents, R53. Record review revealed R53 did not have evidence of their legally appointed guardian's choice for the resident's advance directive, other than their code status. The findings include: Review of facility policy, Advanced Directives and Do Not Resuscitate (DNR) dated 08/2019 revealed the existence of any advance directive was documented in the resident's medical record by filing a copy of all directives on the chart and by making a progress note. The note should include that advance directive information was given to the resident (or the resident's representative if the resident is unable to comprehend.) Documentation of what advance directives the resident has or that they have none should be noted as well. If a resident wished to make an advance directive, they were assisted with information and with the provision of forms. Review of Resident's #53 Face Sheet revealed the facility admitted the resident on 02/28/2020 with diagnoses including bipolar disorder, dysphagia, and chronic obstructive pulmonary disease. Review of Resident's #53 Quarterly Minimum Data Set (MDS) Assessment, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score 15 of 15, indicating resident is cognitively intact. Review of Resident's #53's Comprehensive Care Plan with a revision date of 10/11/2024, revealed a focus of an established Full Code order in place with the intervention that the Advance Directive was reviewed with the resident and/or healthcare decision maker quarterly. Review of Resident's #53's Advance Directive dated 02/28/2020 revealed a signed Do Not Resuscitate (DNR) stating the resident was a Do Not Resuscitate status and an order declaring their son as appointed guardian and conservator. Review of Resident #53's medical record revealed there was no signed Advance Directive in the chart. On 11/13/2024 at 4:00 PM, the State Survey Agency (SSA) Surveyor requested documentation the facility reviewed Advance Directive materials with the resident or representative upon the resident's admission, quarterly, or thereafter. The facility failed to provide documentation. In an interview with Social Services Director (SSD) on 11/15/2024 at 9:29 AM, the SSD stated Resident #53's advance directive was a DNR on admission. The SSD stated Resident #53 went out for psychiatric treatment for a few days and returned to facility on 11/22/2021 with a request to change code status to Full Code. The change was documented as a note in the resident's chart by SSD. The note also stated the guardian agreed to change of status to Full Code. In an interview with Director of Nursing (DON) on 11/15/2024 at 2:13 PM, the DON stated the responsible staff for completing Advance Directives were Social Services and Admissions, collaboratively. Admissions was an online process with electronic forms submitted and Advance Directives were not part of the electronic process. Advance Directives were manually done by Social Services. The purpose of an Advance Directive was the resident or their Power of Attorney, (POA) or decision maker's wishes regarding the resident's code status. A potential outcome for a resident who does not have an Advance Directive was in case of an emergency, the resident was automatically a full code with full life saving measures implemented. In an interview with Administrator on 11/15/2024 at 2:38 PM, they stated the responsible staff for processing Advance Directives was Social Services and Admissions. The Admission Director referred residents and family members to Social Services. The Advance Directive was uploaded to electronic medical record or placed in a hard chart. A change in code status was communicated to nursing staff or social services with additional education provided, care plan was updated, and staff reviewed during daily meeting. The purpose of an Advance Directive was to have the correct life saving measures specific to the resident's care. A potential outcome with no Advance Directive in place meant resident was a full code.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure drugs or biologicals were stored in accordance with State and Federal laws. Observations revealed one (1) of four (4) medication carts was unlocked and unsupervised. Additionally, observations revealed an opened and unlabled container of insulin available for use in the refrigerator in one (1) of four (4) medication refrigerators. Furthermore, record review revealed the facility failed to routinely perform glucometer testing as recommended by the manufacturer on four (4) of four (4) medication cart glucometers. The findings include: 1. Review of facility policy Medication Storage, revised 11/01/17, revealed Controlled substances were stored under double lock and the medication cart was locked at all times, when not under the direct physical supevision of a licensed nure or medication aide. Observation of the South Hall, on 07/12/19 at 1:37 PM, revealed the medication cart was unlocked and unsupervised. Continued observation revealed the South Hall medication cart remained unlocked and unattended until 1:50 PM. Interview with Licensed Practical Nurse (LPN) #1, on 07/12/19 at 4:45 PM, revealed staff locked medication carts when the cart was unattended. LPN #1 stated a locked cart provided safety to residents and anyone in the facility, and each nurse was responsible for the security of their assigned medication cart. LPN #1 stated the facility educated staff to keep medication carts locked when away from the medication cart. Interview with LPN #5, on 07/12/19 at 4:47 PM, revealed staff locked medication carts before they walked away from the medication cart. LPN #5 stated a resident or a visitor may access an unlocked medication cart and injure themselves or another resident with the medications in the medication cart. Interview with the Unit Manager (UM), on 07/12/19 at 5:02 PM, revealed staff were to keep medication carts locked anytime they were away, two (2) to three (3) steps away, from the medication cart. The UM stated anyone could remove items from an unlocked medication cart, ingest something, and a medical issue develops. The UM stated she did not conduct formal audits of medication cart security but would monitor informally when out on the unit; and the SDC educated staff on medication cart security during the initial orientation to the facility. Interview with the Interim Director of Nursing (DON), on 07/12/19 at 6:01 PM, revealed staff locked medication carts when they were away from the cart. The DON stated staff kept medication carts locked to prevent just anyone from accessing medications. She stated the facility had not identified concerns with unlocked and unsupervised medication carts. Interview with the Administrator, on 07/12/19 at 6:52 PM, revealed medication carts should be locked when unattended. She stated anyone could access medications if staff left the medication cart unlocked and unattended. The Administrator stated no previous issues with medication cart security were identified by the facility and role of the facility was to keep residents safe. 2. The facility did not provide a policy related to labeling of medication containers. Observation of the medication refrigerator, on 07/11/19 at 9:38 AM, revealed an opened, unlabled, multi-dose vial of Humalog insulin available for staff use. Interview with the Staff Development Coordinator (SDC), on 07/12/19 at 5:30 PM, revealed staff labeled and dated medication containers when initially opened. The SDC stated proper labeling ensured product was not out of date and residents received effective treatment. She stated the facility provided only verbal education to staff regarding labeling and dating of medication containers as issues arose. Interview with the Interim Director of Nursing (DON), on 07/12/19 at 6:01 PM, revealed staff labeled multi-use medication containers when first opened which then indicated when the medication should be discarded. She stated unlabeled medication could be out of date and not have the intended effect on a resident. The DON stated she was not aware of any audit tools utilized by the facility regarding labeling of medication containers. Interview with the Administrator, on 07/12/19 at 6:52 PM, revealed the facility conducted audits of medication container labeling and had not identified any concerns. 3. The facility did not provide a policy specific to quality control checks of glucose monitoring devices. Review of the Assure Platinum Blood Glucose Monitoring System Quality Assurance / Quality Control (QA/QC) Reference Manual, undated, revealed the following recommendations in Section E, to perform Quality Control: on each day of use, two controls (high & low) should be performed per instrument; each operator to perform a quality control prior to the first patient test of the day; and, quality control procedures performed at least once each day on each instrument used for resident testing. Review of the Quality Control Record for the East Unit glucose monitoring device, for (MONTH) through (MONTH) 11, 2019, revealed no documentation of glucose device testing recorded on 04/19/19, 05/20/19, 05/21/19, 05/22/19, 05/25/19, 07/05/19, 07/06/19, and 07/08/19. Review of the Quality Control Record for the South Unit glucose monitoring device, for (MONTH) 2019 through (MONTH) 11, 2019, revealed no documentation of glucose device testing recorded on 04/20/19, 05/04/19, 05/08/19, 05/26/19, 06/01/19, 06/10/19, and 07/07/19. Review of the Quality Control Record for the West Unit glucose monitoring device, for (MONTH) 2019 through (MONTH) 11, 2019, revealed no documentation of glucose device testing recorded on 04/14/19, 04/20/19, 05/04/19, 05/08/19, 05/26/19, 05/28/19, and 06/01/19. Review of the Quality Control Record for the North Unit glucose monitoring device, for (MONTH) 2019 through (MONTH) 11, 2019, revealed no documentation of glucose device testing recorded on 04/18/19, 07/02/19, 07/05/19, and 07/08/19. Interview with the SDC, on 07/12/19 at 5:30 PM, revealed the facility night shift staff conducted glucometer cleaning and testing nightly. The SDC stated if staff failed to perform glucometer testing as required, the test results could be wrong, impacting the amount of insulin administered to residents. She stated previous random audits of the glucometer test log books revealed missing entries. Interview with the Interim Director of Nursing (DON), on 07/12/19 at 6:01 PM, revealed third shift staff peformed glucometer testing nightly. She stated nightly testing occurred to insure glucometers were performing correctly and if not completed a resident's blood sugar testing results may be incorrect. Interview with the Administrator, on 07/12/19 at 6:52 PM, revealed the facility conducted glucometer testing, but not routinely, with no set time. The Administrator was unable to verbalize a consequence of not conducting glucometer testing other than the results may be incorrect.

Based on observation, interview, and facility policy review it was determined the facility failed to ensure staff labeled and dated food items stored in the refrigerator and freezer. The findings include: Review of the policy Food Storage: Cold, revised (MONTH) 2014, revealed the center insured all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, would be appropriately stored in accordance with guidelines of the USDA Food Code. The policy revealed the Food Services Director / Cook(s) insured all food items were stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the Food and Drug Administration (FDA) (YEAR) Food Code Chapter 3 Subpart 3-501.17 Paragraph (B) revealed except as specified in (E)-(G) of this section, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and if the food is held for more than twenty-four (24) hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container was opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Observation of the walk-in refrigerator, on 07/09/19 at 8:45 AM, revealed one (1) two (2) pound (lb) opened, undated package of smoked turkey breast, one (1) five (5) lb opened, undated bag of shredded mozzarella cheese, one (1) unlabeled container of a jelled substance, one (1) undated bag of diced celery, and one (1) undated bag of shredded lettuce. Observation of the reach-in freezers, on 07/09/19 at 9:15 AM, revealed one (1) opened, undated bag of dinner rolls and one (1) opened, undated bag of diced chicken. Interview with the Account/Dietary Manager during observation revealed dietary staff were responsible for labeling and dating opened packages before returning the food to the refrigerator/freezer because the food could spoil and residents could get sick. Interview with Dietary Aide #2, on 07/12/19 at 10:03 AM, revealed dietary staff should label and date food when it was opened and before it was returned to the refrigerator. She revealed it was important to date opened food to ensure staff did not serve residents spoiled food. Interview with Cook #2, on 07/11/19 at 2:11 PM, revealed dietary staff were responsible for labeling and dating opened packages of food before staff returned the containers to the refrigerator. He stated undated, opened food could potentially spoil and make a resident ill. Further interview with the Dietary Manager, on 07/11/19 at 2:40 PM, revealed he checked the refrigerators and freezers daily to ensure food was labeled/dated. The Manager stated he had not identified any issues related to undated, opened food items until the survey. Interview with the Administrator, on 07/12/19 at 6:53 PM, revealed she audited the kitchen on (MONTH) 3rd and checked for labeling of food in the walk in refrigerator. The Administrator revealed she identified one (1) issue and in-serviced the Dietary Manager.

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain a safe, sanitary environment for residents. Observations revealed one (1) of four (4) medication carts contained a staff member's personal drinking container. The findings include: Review of facility policy The Infection Prevention and Control Program (IPCP), revised 01/22/18, revealed the facility established and maintained an effective program providing safe, sanitary, and comfortable environment, and attempted to prevent the development and transmission of diseases and infections. Additionally, the facility would provide hand hygiene procedures for staff to follow. Observation, on 07/11/19, at 9:25 AM, revealed a sytrofoam, capped, cup of liquid, in the third drawer of the medication cart on the South Unit. Interview with Licensed Practical Nurse (LPN) #2, on 07/11/19 at 9:25AM, revealed the drink cup in the medication cart was hers. LPN #2 stated she was aware staff should not have personal food and drinks in the medication cart as it was an infection control concern and the facility had provided education regarding storing drinks in the medication cart. Interview with the Staff Development Coordinator (SDC), on 07/12/19 at 5:30 PM, revealed she provided education to facility staff on infection control practices, including keeping medication carts clean and not storing personal food in the medication carts. The SDC stated food stored in medication carts was an infection control concern, and may lead to cross contamination and infection. Interview with LPN #5, on 07/12/19 at 4:47 PM, revealed staff were not to store personal food or drinks on/in the medication cart as this was an infection control issue. LPN #5 stated the facility provided education to staff on not storing food items on the medication cart or at the nurses' station and all staff knew not to have drinks in the medication cart. Interview with the Interim Director of Nursing (DON), on 07/12/19 at 6:01 PM, revealed staff kept medication carts clean and did not store personal food or drinks in the medication carts as it was an infection control issue. She stated keeping a drink in a cart could lead to the spread of infection. The DON stated the facility has not identified issues with staff storing food or drinks in the medication carts, and provided frequent verbal education to staff on infection control practices. Interview with the Administrator, on 07/12/19 at 6:52 PM, revealed an expectation that staff follow infection control policy. The Administrator stated she had not identified issues concerning infection control.

Based on observation, interview, and facility policy review it was determined the facility failed to ensure resident dignity during dining. Staff were observed cleaning tables during meal service while residents were seated at the table eating. The findings include: Review of facility policy, Dignity, version (MONTH) 2013, revealed residents were given care and treatment in a manner that preserved their dignity, self-esteem, and self-respect. Each resident was valued as an individual. Observation during dining service, on 07/09/19 at 12:12 PM, revealed the Dietary Manager wiped down tables while residents were seated at the table. Interview with the Manager during observation revealed he would not want the table sanitized while he ate because it was rude; however, he was told to wipe them down. He stated sanitizing the table while a resident ate could make the resident feel rushed. Observation of dining, on 07/09/19 at 12:13 PM, revealed the Interim Director of Nursing (DON) removed soiled plates and sanitized tables during the meal. Further observation, on 07/09/19 at 12:20 PM, revealed she continued to remove soiled meal trays and sanitized tables during the meal. Observation, on 07/09/19 at 12:24 PM, revealed the DON removed a soiled lunch tray and sanitized the table where Resident #71 was seated at the table, eating lunch. Interview with the Licensed Practical Nurse/Unit Manager (UM), on 7/12/19 at 5:02 PM, revealed it was not good practice to clean tables with residents seated at the table. She stated she would not want the table wiped down because it could be a problem if cleaning fluid got into the food. According to the UM, it was important to maintain a homelike environment for residents and stated residents who were unable to verbalize their needs could be bothered by the cleaning during the meal. Interview with the DON, on 07/11/19 at 10:27 AM, revealed tables should not be sanitized if a resident was still seated at the table eating because it was a dignity issue. She stated she would not want her table cleaned while she was eating because it was not sanitary or something might get in the food. Interview with the Administrator, on 07/12/19 at 6:53 PM, revealed it was possible staff cleaned isolated spots while a resident was seated at the table related to the facility's open dining procedure. The Administrator revealed she would not think it was a dignity issue and was not aware of resident concerns related to cleaning the tables during dining.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure the environment was free from accident hazards on one (1) of four (4) nursing units. The North Hall housekeeping closet was unlocked and unsupervised and contained chemicals. The findings include: Review of the Healthcare Services Group Environmental Services Chemical Use/Dilution and Hazards In-service Training revealed staff must follow guidelines in order to help prevent accidents from occurring. The training revealed the door to the janitor's closet must be locked if staff left chemicals inside. Observation on the North Hall, on 07/09/19 at 10:16 AM, revealed the housekeeping closet was unlocked and unattended. Further observation with the Environmental Services Director revealed the following cleaning chemicals stored in the closet: five (5) two (2) liter bottles of HDQL10 disinfectant cleaner, ten (10) two (2) liter bottles of Halt disinfectant cleaner (including one (1) bottle with no cap), two (2) two (2) liter bottles of Tribase multi-purpose cleaner, eight (8) two (2) liter bottles of Biorenewable glass cleaner, and one (1) twelve hundred (1200) milliliter (ml) container of hand sanitizer. The disinfectant and cleaning chemicals were also stored in multiple dispensers on the wall of the closet. Review of the Super HDQL10 disinfectant Safety Data Sheet (SDS), revised 08/14/15, revealed the chemical was harmful if swallowed or with skin contact and caused severe [MEDICAL CONDITION] serious eye damage. Review of the HALT disinfectant SDS, revised 07/27/15, revealed the chemical caused severe [MEDICAL CONDITION] serious eye damage. Review of the Tribase multi-purpose cleaner SDS, revised 08/11/15, revealed the chemical caused serious eye irritation. Review of the Bioreneable glass cleaner SDS, revised 08/05/15, revealed the chemical caused eye irritation, may cause respiratory irritation if inhaled, and may be harmful if swallowed. Review of the Hand Sanitizer SDS, dated 10/15/07, revealed the chemical may cause eye irritation or upset stomach and nausea with ingestion. Interview with Housekeeping Aide #2, on 07/09/19 10:27 AM, revealed she had just returned from break and was not aware the housekeeping closet was unlocked. She stated the closet should be locked when unattended to ensure the safety of residents. Interview with Housekeeping Aide #1, on 07/11/19 at 10:55 AM, revealed the housekeeping closet should be kept locked when unattended because a resident could get in the closet and get hurt. Interview with the Licensed Practical Nurse/Unit Manager (UM), on 07/12/19 5:02 PM, revealed she performed random walk through audits of the environment and was not aware of any recent issues with unsecured housekeeping closets. The UM revealed a resident could potentially access an unlocked closet and burn their skin or ingest a chemical. Interview with the Environmental Services Director, on 07/09/19 at 10:16 AM, revealed the housekeeping closet should be closed and locked to prevent resident access to chemicals. He stated a resident could be exposed to the chemicals, which posed a risk for damage to the eye, throat, or skin, potential ingestion and/or hospitalization . The Director revealed he had not identified any concerns related to unlocked housekeeping closets. Interview with the Administrator, on 07/12/19 at 6:53 PM, revealed chemicals should always be stored, locked and supervised to keep residents safe. The Administrator revealed unsecured chemicals posed a risk for potential spills or resident access.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure twelve (12) hours of annual in-service training was completed for one (1) of five (5) Certified Nurse Assistants (CNA), CNA #7 The findings include: Review of the policy Inservice Training, revised 09/19/11, revealed in-service education was a necessary basis for providing residents with the best possible care. Further review revealed Nursing Assistants were required to attend at least twelve (12) hours of training per year and it was the responsibility of the Staff Development Coordinator/Designee to offer training programs during all three (3) shifts for staff convenience. The policy revealed the facility would post in-service hours accumulated per quarter for each Nursing Assistant in order to keep facility and staff current with the requirement, and mandatory in-services included Care for Residents with Dementia. Review of the facility's annual In-Service Training Records revealed CNA #7 did not attend 12 hours of training per year. Interview with the Staff Development Coordinator (SDC), on 07/12/19 at 11:22 AM, revealed she was responsible for ensuring CNA's received twelve (12) hours of annual in-service education, including dementia training. She revealed she monitored the training forms to ensure staff received the annual education; however, she failed to notice that CNA #7 did not attend 12 hours of training as required. The SDC further revealed some CNA's miss training due to leave or scheduling conflicts; however, she had not followed up to ensure the training was provided when CNA's returned to work. The SDC revealed she left notes for CNA's at the nurses' station reminding the CNA's of the required training. According to the SDC, the facility could not mandate staff to attend in-service trainings. She stated it was important to educate CNA's regarding dementia care in order to provide better care for residents. Interview with the Interim Director of Nursing (DON), on 07/12/19 at 6:03 PM, revealed the SDC was responsible for providing and tracking annual CNA education to ensure the facility met the mandatory requirements. The DON revealed she was not aware any CNA's missed training on dementia care. According to the DON, training was important for staff to maintain current skills to provide better care to residents. Interview with the Administrator, on 07/12/19 at 6:53 PM, revealed the SDC reviewed training records monthly to ensure CNA education was current. She stated she recently reviewed the records and was not aware of any issues related to any missed education. The Administrator revealed staff not meeting the requirements would complete the training before they worked again.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of three (3) sampled residents, Resident #1. Review of the resident's care plan revealed staff was to observe the resident during ambulation for endurance and steadiness, and monitor for safety awareness; however, on 06/11/18, the resident attempted to go out to the patio, unassisted, and sustained a fall that resulted in a fracture. Staff utilized information on the Resident Care Guide related to supervision, which differed from the Comprehensive Care Plan. The findings include: Review of the facility's policy, Resident Care Plan, dated 11/13/17, revealed resident care plans would be an ongoing process and would include current problems and/or needs identified from a complete assessment including the Minimum Data Set (MDS) and Care Area Assessments relevant to the resident's health status. The policy also revealed any identified needs of the resident would be addressed by the appropriate disciplines. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 05/17/16, with [DIAGNOSES REDACTED]. Review of Resident #1's Annual MDS, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of eleven (11) out of fifteen (15) and determined the resident interviewable. The facility assessed the resident required supervision when ambulating off the unit and utilized a walker. The facility determined the resident had one (1) non-injury fall since the last assessment. Review of Resident #1's Quarterly MDS, dated [DATE], revealed the facility determined the resident was interviewable with a BIMS score of nine (9) out of fifteen (15). Review of Resident #1's Comprehensive Care Plan, dated 04/25/18, revealed the resident required supervision and occasional physical assistance for mobility and utilized a walker to ambulate. Interventions directed staff to observe ambulation for endurance and steadiness and monitor for safety awareness. The care plan also revealed Resident #1 was at risk for falls and staff should monitor and intervene for factors causing falls, which included monitoring the resident's mobility. Review of Resident #1's Care Guide, not dated, revealed the resident ambulated independently and had no special precautions listed. Review of Resident #1's Nursing Progress Notes, dated 06/11/18, revealed the resident attempted to ambulate through the doorway using a walker and fell . Review of Resident #1's Event/Incident Report, dated 06/11/18, revealed staff did not observe the resident's fall. Review of Resident #1's hospital Discharge Summary, dated 06/14/18, revealed the hospital admitted the resident on 06/11/18 and discharge him/her on 06/14/18 with principle [DIAGNOSES REDACTED]. The Discharge Summary notes revealed after dinner, Resident #1 went outside to the facility's patio area and tripped over the door strip, fell , and landed on the left side. Observation of Resident #1, on 08/07/18 at 9:10 AM, revealed the resident seated in the dining room finishing breakfast. The resident used his/her walker and left the dining room, and went down the hallway to his/her room. Attempted interview with Resident #1, on 08/07/18 at 9:25 AM, revealed the resident smiled when asked questions and did not reply. Interview with Resident #2, on 08/07/18 at 9:25 AM, revealed he/she was Resident #1's spouse and stated Resident #1 was prone to falling after suffering a stroke. Resident #2 stated they liked to go out to the patio after dinner and staff was busy in the dining room and often unavailable to assist them through the patio doors. Record review revealed the facility assessed Resident #2 on 05/19/18 with a BIMS score of eleven (11) out of fifteen (15) and determined the resident interviewable. Interview with Unsampled Resident B, on 08/07/18 at 8:40 AM, revealed he/she witnessed Resident #1 fall approximately two (2) months ago. He/she stated Resident #1 came out of the facility and lost his/her balance. Unsampled Resident B stated staff was not around to assist the resident. The facility determined Unsampled Resident B was interviewable with a BIMS score of fifteen (15) out of fifteen (15) on 06/28/18. Interview with Certified Nursing Assistant (CNA) #3, on 08/07/18 at 11:07 AM, revealed residents independently entered/exited the patio doors, but if they asked staff for help, we would assist them. Interview with Unsampled Resident C, on 08/07/18 at 1:05 PM, revealed if he/she wanted to go out in the patio area, he/she had to help himself/herself through the patio doors or not go out because staff was not always present to assist. The facility determined Unsampled Resident C was interviewable with a BIMS score of fifteen (15) out of fifteen (15) on 06/11/18. Interview with Family Member #1, on 08/07/18 at 2:00 PM, revealed when she arrived at the facility on 06/11/18, Resident #1 was laying on the floor. Family Member #1 stated she often witnessed Resident #1 going in and out of the patio door unassisted. Interview with CNA #4, on 08/07/18 at 2:13 PM, revealed most of the residents were physically unable to open the patio doors and required assistance. CNA #4 stated Resident #1 needed assistance with opening the patio doors when he/she wanted to go outside because it was difficult for him/her to walk through with the walker and hold the doors open. CNA #4 also stated Resident #1 had difficulty balancing himself/herself and if staff was not available to help get through the patio doors, he/she could fall and get hurt. She stated she was never educated or directed to assist residents through the patio doors. Interview with Licensed Practical Nurse (LPN) #1, on 08/07/18 at 3:07 PM, revealed on 06/11/18 at approximately 5:30 PM, she was at the nurses' station charting and looked up and saw Resident #1 on the floor in the vestibule area between the set of double doors leading to the patio. LPN #1 stated there was no staff present to assist the resident when the incident occurred. According to LPN #1, when Resident #1 fell , the resident was attempting to go out on the patio. She stated she did not know how Resident #1 fell , nor did other staff because no one witnessed the fall. Interview with CNA #6, on 08/08/18 at 11:45 AM, revealed she utilized the Resident Care Guide and it stated Resident #1 did not require supervision, but after reading the Comprehensive Care Plan, she stated the Resident Care Guide was not correct and she should have monitored Resident #1 when he/she was ambulating. According to CNA #6, staff did not appropriately monitor Resident #1 for steadiness. CNA #6 also stated she was not trained to read or follow resident Comprehensive Care Plans; she was only trained to read/follow the Resident Care Guides. Interview with CNA #8, on 08/09/18 at 3:15 PM, revealed during dinner, staff was very busy and could not supervise all the residents. She stated she was only trained on how to supervise residents during smoking times. Interview with LPN #2, on 08/09/18 at 3:52 PM, revealed the MDS Nurse developed and/or revised resident care plans and staff was responsible for following them, as directed. She stated according to Resident #1's Resident Care Guide, he/she did not need staff assistance or supervision because he/she was independent. She stated Resident #1 walked to the dining room by himself/herself and after eating, went outside on the patio by himself/herself. LPN #2 stated she thought she knew what supervision the residents required because she reviewed their Resident Care Guides and received shift change report. Interview with LPN #3, on 08/09/18 at 4:24 PM, revealed she was Resident #1's nurse when the resident fell and was providing care for a new resident when the fall occurred. According to LPN #3, staff was not assisting or observing Resident #1 when he/she fell , but the resident required supervision when ambulating because he/she would lose balance and staff should be ready to intervene, if necessary. She stated care plans directed staff on how to provide care for residents and staff should always follow the residents' care plans. She further stated staff was not following Resident #1's care plan the night the resident fell because they were not monitoring him/her ambulate out to the patio. She also stated the Director of Nursing (DON) in-serviced nursing staff on following care plans in orientation, when they met every other Thursday, and as needed. Interview with the Unit Manager, on 08/09/18 at 5:18 PM, revealed if staff did not appropriately supervise residents while ambulating according to their care plans, residents could get hurt. She stated staff was directed and trained to follow residents care plans. She stated she monitored staff by observing, and reviewing resident care plans, to ensure residents received supervision according to their care plans. The Unit Manager stated Resident #1's care plan directed staff to observe ambulation for endurance and steadiness; however, the Resident Care Guide noted the resident ambulated independently. The Unit Manger admitted it was confusing, but she knew the residents and what type of supervision they required, without looking at the paperwork. Interview with the Quality Assurance Nurse, on 08/10/18 at 10:00 AM, revealed resident care plans kept staff informed of the individual resident's care needs and how they should provide those needs. She stated CNAs did not have access to resident care plans and were directed to utilize the Resident Care Guides. Interview with the MDS Coordinator, on 08/10/18 at 10:33 AM, revealed resident care plans mapped out the residents' care needs and gave direction to staff on how to care for the residents. She stated Resident #1's care plan directed staff to observe the resident when ambulating and required them to observe the resident for steadiness and endurance. She stated an accident could occur if staff did not provide supervision, per the care plan. She developed and revised all resident care plans and they were reviewed in the Interdisciplinary Team Meetings for accuracy. The MDS Coordinator stated staff could only observe residents when they were in their presence. Interview with the DON, on 08/10/18 at 11:30 AM, revealed she knew staff needed more training on reading and following resident care plans verses the Resident Care Guides. She stated she previously trained staff on following care plans, but there was always a need for re-training. Interview with the Administrator, on 08/10/18 at 3:00 PM, revealed the Interdisciplinary Team met every morning to discuss events and issues going on within the facility and any changes or updates with the residents, which included discussing and reviewing resident care plans. She stated the clinical team established the care plans and she expected staff to follow the care plans to maintain the residents' welfare.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received the supervision and assistance needed to prevent an accident for one (1) of three (3) sampled residents, Resident #1. The facility was aware residents in wheelchairs and residents with walkers had difficulty entering/exiting the patio door; however, Resident #1, who the facility assessed was at risk for falls and had a history of [REDACTED]. The findings include: The facility did not provide a policy regarding resident supervision. Review of clinical record for Resident #1 revealed the facility admitted the resident on 05/17/16, with [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident required supervision for locomotion off the unit and utilized a walker for mobility. The facility determined the resident had one (1) non-injury fall since the last assessment. The facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15) and determined the resident interviewable. Review of Resident #1's Quarterly MDS, dated [DATE], revealed the facility determined the resident was interviewable with a BIMS score of nine (9) out of fifteen (15). Review of Resident #1's Comprehensive Care Plan, dated 04/25/18, revealed the resident required supervision and occasional physical assistance for mobility. Resident #1 utilized a walker to ambulate. Interventions included staff to observe ambulation for endurance and steadiness and to monitor for safety awareness. Resident #1 was at risk for falls and staff should monitor and intervene for factors causing falls, which included monitoring the resident's mobility. Review of Resident #1's Care Guide, not dated, revealed the resident ambulated independently and had no special precautions listed. Review of Resident #1's Nursing Progress Notes, dated 06/11/18, revealed the resident attempted to ambulate through the doorway using a walker and was noted lying on the floor. The resident was unable to perform range of motion to the lower left extremity due to severe pain. Staff notified the nurse practitioner and received an order to send Resident #1 to the emergency room for evaluation and treatment. Review of Resident #1's Event/Incident Report, dated 06/11/18, revealed staff did not observe the resident's fall. Review of Resident #1's hospital Discharge Summary, dated 06/14/18, revealed the hospital admitted the resident on 06/11/18, and discharged him/her on 06/14/18 with a principle [DIAGNOSES REDACTED]. The hospital's Discharge Summary revealed after dinner, Resident #1 and her/her spouse went outside to the patio at the nursing home. When returning into the building using a walker, Resident #1 tripped over the door strip, fell , and landed on the left side. Resident #1 was immobilized with immediate onset of hip and lower left extremity pain. The Discharge Summary noted Resident #1 tolerated surgery without difficulty. Interview with the Physician, on 08/07/18 at 11:40 AM, revealed Resident #1 sustained a fractured femur from the fall, which caused severe pain. Observation of the patio entrance/exit doors, on 08/07/18 at 8:31 AM, revealed the patio doors were located within view of the nurses' station and contained two (2) sets of glass double doors. There was a small vestibule area between the two (2) sets of double doors. There were handicap accessible push buttons to enter and exit the patio. Observation of Resident #1, on 08/07/18 at 9:10 AM, revealed the resident was seated in the dining room finishing breakfast. The resident stood, grabbed his/her walker, and walked down the hallway to his/her room without staff supervision, as required by the plan of care. Interview with Resident #1, on 08/07/18 at 9:25 AM, was unsuccessful as the resident only smiled and did not reply to questions. Interview with Resident #2, Resident #1's spouse, on 08/07/18 at 9:25 AM, revealed Resident #1 was prone to falling after suffering a stroke. Resident #2 stated he/she and Resident #1 liked to go out onto the patio and sit after dinner. The resident also stated when they went out to the patio; staff was busy in the dining room and often unavailable to assist them through the patio doors. Record review revealed the facility assessed Resident #2 on 05/19/18 with a BIMS score of eleven (11) out of fifteen (15) and determined the resident interviewable. Interview with Unsampled Resident A, on 08/07/18 at 8:36 AM, revealed the facility had automatic door openers installed on the doors leading to the patio approximately two (2) weeks ago because some residents were having trouble entering and/or exiting the doors. Unsampled Resident A stated a resident (Resident #1) fell in between the set of double doors and the facility rushed the resident to the hospital. The facility determined Unsampled Resident A was interviewable with a BIMS score of thirteen (13) out of fifteen (15) on 06/28/18. Interview with Unsampled Resident B, on 08/07/18 at 8:40 AM, revealed he/she witnessed Resident #1 fall approximately two (2) months ago. The resident stated Resident #1 was coming out of the building and lost his/her balance and staff was not around to assist the resident open the door. According to Unsampled Resident B, residents who ambulated utilizing wheelchairs and walkers had a lot of trouble getting in/out the patio doors before the facility installed the handicap accessible door push buttons (automatic door opener). The facility determined Unsampled Resident B was interviewable with a BIMS score of fifteen (15) out of fifteen (15) on 06/28/18. Interview with Certified Nursing Assistant (CNA) #3, on 08/07/18 at 11:07 AM, revealed residents independently entered/exited the patio doors, but if they asked staff for help, staff assisted them. CNA #3 stated some of the residents asked for help and some did not. CNA #3 also stated after Resident #1 hurt himself/herself coming through the patio doors, the facility did not direct staff to provide assistance for residents when they entered or exited the patio doors. Interview with CNA #4, on 08/07/18 at 2:13 PM, revealed most of the residents were physically unable to open the patio doors, and required supervision and assistance. CNA #4 stated Resident #1 and #2 needed assistance with opening the patio doors because it was difficult for them to walk through with their walkers and hold the doors open. CNA #4 also stated Resident #1 and #2 had difficulty balancing themselves and if staff was not available to help them through the patio doors, they could fall and get hurt. She stated she was never educated or directed to assist residents through the patio doors, but when she saw a resident try to open the doors and go through, she would help them out of courtesy. Interview with CNA #6, on 08/08/18 at 11:45 AM, revealed the facility installed the automatic door openers after Resident #1 fell and broke a bone. CNA #6 stated she utilized the Resident Care Guide and it stated Resident #1 did not require supervision, but after reading the Comprehensive Care Plan, she stated the Resident Care Guide was not correct and she should have observed Resident #1 when he/she was ambulatory. According to CNA #6, staff did not appropriately supervise Resident #1 for steadiness. Interview with CNA #1, on 08/09/18 at 11:40 AM, revealed he worked the day Resident #1 fell , but did not witness the incident because he was assisting another resident. He stated staff was directed to only assist the supervised smoking residents outside to the patio. He stated since the facility placed the automatic door openers on the patio door, it was much easier to take the residents in wheelchairs outside. Interview with CNA #7, on 08/09/18 at 2:30 PM, revealed the heaviness of the patio doors presented a potential fall and/or safety risk for residents because most of the residents were physically unable to independently open the doors and utilize their wheelchairs and/or walkers when going over the threshold. She stated she heard a scream and found out later that Resident #1 fell going out onto the patio. According to CNA #7, there were two (2) meal groups and the first group consisted of residents that were able to independently eat and the second group needed assistance. She stated there were at least six (6) CNAs and two (2) nurses in the dining room during the second meal. CNA #7 further stated Resident #1 and #2 often went outside on the patio after dinner without assistance from staff. She stated she cared for Resident #1 the night he/she fell , but did not witness the fall because she was in the dining room assisting residents with their meals. Interview with CNA #8, on 08/09/18 at 3:15 PM, revealed she worked the night Resident #1 fell and at the time of the fall, she was assisting other residents. She stated during dinner, staff was very busy and could not supervise all residents. She further stated there were only two (2) CNAs working the hallways passing trays and answering call lights during dinner. CNA #8 stated she was only trained on how to supervise residents during smoking times. Interview with Licensed Practical Nurse (LPN) #1, on 08/07/18 at 3:07 PM, revealed on 06/11/18 at approximately 5:30 PM, she looked up she saw Resident #1 on the floor in the vestibule between the set of double doors leading to the patio. LPN #1 stated Resident #2 stood beside Resident #1 and no staff was present to assist the residents when the incident occurred. LPN #1 stated she walked over to assess Resident #1 and the resident was unable to complete range of motion to the left leg due to pain. According to LPN #1, when Resident #1 fell , he/she was attempting to go out to the patio. She stated she did not know how Resident #1 fell , nor did other staff because no one witnessed the fall. LPN #1 stated she had safety concerns for the residents because it was not easy pushing the doors open and the residents rarely asked staff to assist them through the doors. Interview with LPN #2, on 08/09/18 at 3:52 PM, revealed Resident #1 and #2 did not need staff assistance or supervision because they could care for themselves. However, the plan of care required staff to provide supervision when ambulating for endurance and steadiness. She stated they walked to the dining room by themselves and after they finished eating, went outside on the patio by themselves. She stated she worked the night Resident #1 fell , but could not recall what she was doing or where she was at the time of the fall. Interview with LPN #3, on 08/09/18 at 4:24 PM, revealed she was the nurse assigned to Resident #1 when the resident fell . She stated she was providing care for a new resident when the fall occurred. LPN #3 also stated none of the staff were assisting or observing Resident #1 when he/she fell , but the resident required supervision when ambulating because he/she would lose balance and staff should be ready to intervene, if necessary. Interview with Unsampled Resident C, on 08/07/18 at 1:05 PM, revealed he/she loved to go outside on in the patio area and since the facility added the automatic door opener, he/she felt more independent because the doors were hard to open. The resident stated prior to the automatic door opener, if he/she wanted to go out to the patio area, he/she had to help himself/herself through the doors or not go out because staff was not always present to assist. The facility determined Unsampled Resident C was interviewable with a BIMS score of fifteen (15) out of fifteen (15) on 06/11/18. Interview with the Maintenance Director, on 08/07/18 at 11:20 AM, revealed the facility had the automatic door opener installed a couple of months ago to make it accessible for residents with disabilities to enter/exit the building onto the patio area when they went out to smoke or wanted to enjoy the weather outside. He stated the residents utilized the patio doors multiple times during the day and had to physically push the doors open and hold them open to walk or roll through them. Interview with Family Member #1, on 08/07/18 at 2:00 PM, revealed she often witnessed residents going in and out of the patio door unassisted. Family Member #1 also stated staff was not allowed to assist the residents and often complained about the difficulties the residents had going in/out the patio doors and felt one of the residents were going to get hurt. She stated those doors were dangerous and the Administrator had received multiple complaints from residents, staff, and family members regarding the facility's entrance/exit doors. Interview with Unsampled Resident D, on 08/07/18 at 3:00 PM, revealed the resident presided over Resident Counsel Committee meetings and had repeatedly informed the Unit Manager and Social Services Director about residents having trouble opening the doors, including the patio entrance, front entrance, and side entrance doors. Unsampled Resident D stated most residents utilized assistive devices (wheelchairs, walkers, or canes) to ambulate. Unsampled Resident D further stated over the years, multiple residents had accidents attempting go through the doors. The facility determined Unsampled Resident D was interviewable with a BIMS score of fifteen (15) out of fifteen (15) on 05/12/18. Review of the Resident Council Meeting Minutes, dated 05/30/18, revealed an Administrator addendum regarding the patio door glass was broken due to a wheelchair pushing through it and a reminder to the residents to ask for assistance if they were not able to get through the door by themselves. Interview with the Social Services Director, on 08/07/18 at 3:45 PM, revealed she could not remember if Unsampled Resident D complained to her about residents having difficulty opening the doors. However, the Administrator announced a few months ago the facility was adding an automatic door opener to the patio doors to make it easier for the residents to access the patio area. She stated the Administrator reminded residents to ask staff for assistance if they needed help entering and/or exiting facility doors. Interview with the Ombudsman, on 08/09/18 at 9:54 AM, revealed she was present in the Resident Council Meeting held on 05/30/18 and the Administrator reminded the residents to ask staff for help if they wanted to go outside to the patio area. However, some of the residents stated staff was not always available and some staff refused to assist them when they asked. Interview with Physical Therapist Assistant #1, on 08/08/18 at 9:35 AM, revealed the therapy department had concerns with residents attempting to enter/exit facility doors by themselves. She stated the residents needed assistance or close supervision when entering and/or exiting the facility doors to prevent them from being hurt. Interview with Family Member #2, on 08/08/18 at 11:35 AM, revealed once when she visited the facility, a resident's hands were stuck in the double doors leading to the patio area as he/she attempted to go through the door. Family Member #2 stated staff was standing at the nurses' station and not paying attention to the resident. She stated the Unit Manager told the resident he/she was not allowed to go back outside. Interview with the Unit Manager, on 08/09/18 at 5:18 PM, revealed if staff did not appropriately supervise residents when they ambulated, residents could get hurt. Interview with the Quality Assurance Nurse, on 08/10/18 at 10:00 AM, revealed she investigated Resident #1's fall incident/accident and no staff reported they witnessed Resident #1's fall. She stated she did not consider or look at the patio doors when she investigated the resident's fall. She stated she determined the root cause of Resident #1's fall was the resident became unbalanced and tripped on the door's threshold. Interview with CNA #9, on 08/10/18 at 11:01 AM, revealed the patio doors have always been a safety concerns because the residents would get caught in between the doors when they closed. She stated the CNAs had told the nurses about it because they did not want the residents to get hurt. Interview with the MDS Coordinator, on 08/10/18 at 10:33 AM, revealed Resident #1's Accident/Incident Report Form indicated the resident's fall was not observed by staff on duty. The care plan directed staff to observe the resident when ambulating for steadiness and endurance. She stated an accident could occur if staff did not provide supervision, per the care plan, and cause the resident to become injured. Interview with the Director of Nursing (DON), on 08/10/18 at 11:30 AM, revealed staff should supervise resident mobility according to interventions on the care plan. According to the DON, she always instructed staff to assist residents out the facility's doors. The DON further stated she had no documented evidence she monitored staff for implementation of supervision to monitor resident safety. However, she stated staff needed more training on following resident care plans. Interview with the Administrator, on 08/10/18 at 3:00 PM, revealed the Interdisciplinary Team met once a day in the mornings to discuss events and issues going on within the facility and any changes or updates with the residents, including accidents/incident reports (falls). She stated it was the facility's responsibility to monitor/observe residents assessed as fall risks, but she referred all medical concerns to the DON. In addition, she stated she was ultimately responsible for all staff actions within the facility.

Based on observation, interview, and facility policy review, it was determined the facility failed to serve food in a sanitary manor. Observation revealed dietary staff cross contaminating foods with gloved hands during the meal service. The findings include: Review of the facility's policy, Resident Meal Service, dated (MONTH) 2013, revealed plastic gloves were to be used during service and plastic gloves were to be changed when an interruption in a single task occurred. Observation of the kitchen tray line, on 05/01/18 12:09 PM, revealed Cook #1 touched several food utensils, his pant legs, the steam table ledge, and then touched three (3) slices of cheese, three (3) slices of bread, two (2) servings of potato chips ,and two (2) pin-wheel sandwiches. The cook did not change his gloves after he touched non-clean items and before he touched clean items, which caused cross-contamination of residents' food. Interview via telephone, on 05/02/18 at 2:11 PM, with Cook #1 revealed he knew not to touch clean items with gloved hands that had touched non-clean item,s without first changing his gloves and washing his hands. He stated he must have gotten busy and it, missed his mind, which caused cross-contamination. Cook #1 stated cross-contamination of foods could possibly make a resident ill. Interview with the Dietary Manager, on 05/02/18 4:33 PM, revealed he expected Cook #1 to change his gloves, wash his hands, then put on new gloves, when the Cook cross contaminated the food. The Dietary Manager stated it was possible a resident could get sick by cross-contamination. Interview with the Administrator, on 05/02/18 4:45 PM, revealed cross contamination of food was a facility concern, and safe food handling was the standard protocol for the facility. She stated the dietary staff had received training regarding cross-contamination and safe handling of food. Review of the Cook #1's file revealed he had received training from the Department of Public Health and Wellness on Sanitation for Foodservice Managers, on 02/22/18.

Based on observation, interview, record review, review of the facility's Admission Packet and review of the Resident Services Handbook, it was determined the facility failed to ensure privacy during perineal care for two (2) of sixteen (16) sampled residents, (Residents #3 and #12). Certified Nursing Assistant (CNA) #4 and Registered Nurse (RN) #1 failed to provide privacy during incontinent and catheter care for Resident #3, and CNA #5 and #6 failed to provide privacy during incontinent care and a brief change for Resident #12. The findings include: Review of the facility's Admission Packet revealed a document titled Federal Rights, revised February 1998, which read the resident had the right to personal privacy and was described to mean the resident could have privacy in his/her medical treatment and personal care. Review of the Resident Services Handbook, revised 04/07/08, revealed each resident's individual privacy and dignity would be maintained when personal care and treatments were administered. 1. Review of the clinical record for Resident #3 revealed the facility readmitted the resident on 01/06/15 with [DIAGNOSES REDACTED]. The facility assessed Resident #3 with a Brief Interview for Mental Status (BIMS) score of four (4) on 03/07/15 and determined the resident was not interviewable. The facility also assessed Resident #3 as needing extensive assist of one (1) person for self care in toileting and in personal hygiene on 03/07/15. Observation, on 02/03/16 at 2:20 PM, revealed Certified Nursing Assistant (CNA) #4 at the bedside of Resident #3 who was lying supine, on top of the bed linens of his/her bed dressed in street clothing. CNA #4 pulled the resident's slacks down around his/her ankles to change the resident's brief (an incontinence garment) and provide incontinence care. Resident #3's roommate was in Bed 2 of the room and was lying on his/her left side facing the bed of Resident #3. The window blinds to the room were open and the privacy curtain was not pulled between the two (2) residents nor was the privacy curtain pulled on the side of Resident #3's bed closest to the room door. No sheet or blanket was used at that time to cover Resident #3 leaving his/her lower abdomen, mons pubis, perineum, thighs, knees and lower legs exposed. Interview with CNA #4, on 02/04/16 at 1:23 PM, revealed she had been trained to respect the privacy of all residents during personal care by the facility upon hire and yearly. She knew she should ensure the privacy of all residents regardless of their cognition and she had failed to ensure the privacy of Resident #3 during a brief change and incontinence care. She was nervous with the surveyor in the room and that was why she failed to ensure the privacy of Resident #3. She should have covered the resident with a sheet and pulled the privacy curtains, but she had just forgotten. Observation, on 02/04/16 at 9:53 AM, revealed Registered Nurse (RN) #1, at the bedside of Resident #3 who was lying supine, on top of the bed linens of his/her bed dressed in a blouse and skirt. RN #1 removed Resident #3's skirt to provide indwelling catheter care and perineal care to the resident. RN #1 removed the resident's incontinence garment with no privacy afforded to the resident's lower abdomen, mons pubis, perineum, thighs, knees and lower legs with a sheet or blanket. In addition, the privacy curtain between the resident's bed and the bedroom door was not pulled to ensure the resident's privacy during personal care. Interview with RN #1, on 02/04/16 at 1:55 PM, revealed she knew she should ensure the privacy for all residents during personal care, but she forgot to do so during Resident #3's perineal and catheter care. She had been trained to respect the privacy of all residents during personal care and she had failed to do so during the incontinence and catheter care she gave to Resident #3 that morning. She should have pulled the privacy curtains and covered Resident #3 with a sheet to afford his/her privacy. 2. Review of the clinical record for Resident #12 revealed the facility readmitted the resident on 08/24/11 with [DIAGNOSES REDACTED]. On 12/19/15 the facility assessed Resident #12 with a BIMS score of three (3) and determined the resident was severely cognitively impaired. The facility also assessed Resident #12 as always incontinent of urine and needing two (2) or more persons to assist him/her with personal hygiene and brief changes. Observation, on 02/03/16 at 3:45 PM, revealed Resident #12 was in the room lying on his/her right side on the bed facing the window. He/she was alert and oriented to self and reported that he/she had worked at a local hospital for over twenty (20) years. He/she was fully dressed in clean street clothes and was well groomed. Observation, on 02/04/16 at 9:30 AM, revealed CNA #5 and CNA #6 performed a brief change and incontinent care of Resident #12. The resident was lying partially exposed and supine in bed. Resident #12's clothing was removed from the waist down with an unfastened brief loosely gathered around the perineum. There was no sheet or towel to cover the lower legs and thighs and the privacy curtain was not pulled around the bed. The brief was then removed from Resident #12 and incontinent care was provided. There was no privacy afforded to Resident #12 while the perineal area was bare. Resident #12 complained that they were cold and no sheet, towel or blanket was provided to Resident #12 for comfort or privacy at any time during the incontinent care procedure. The privacy curtain remained open. After the clean brief was positioned and fastened, CNA #6 stated she was going down the hall to get Resident #12 a blanket. At 9:40 AM, CNA #6 left the room leaving the door open behind her, exposing Resident #12's lower legs and thighs to persons in the hallway outside. Observation, on 02/04/16 at 11:40 AM, from the hallway, revealed Resident #12 was in his/her bed with an exposed perineum as CNA #5 changed him/her. Resident #12 was exposed from the hallway a second time when the Director of Nursing entered the room. The privacy curtain was not pulled between the beds and there was no sheet, blanket or towel covering the lower half of Resident #12's body. Interview with CNA #6, on 02/04/16 at 1:10 PM, revealed she believed privacy was important for all residents, regardless of their cognitive ability. She stated she had been trained to shut the door, pull the curtain and to respond to knocks on the door by asking who it was before allowing entry. She had not received patient privacy training from the facility, as she was an agency CNA, but considered it a basic standard of care. CNA #6 stated she did not pull the curtain or screen person/s before entry. Interview with CNA #5, on 02/04/16 at 1:30 PM, revealed she had been trained by the facility Staff Development Coordinator (SDC) to provide privacy to residents by closing the door, pulling the curtain and responding to any knocks on the door by yelling patient care to indicate not to enter. She thought the curtain was pulled enough to protect Resident #12 during his/her brief change, but then remembered that the SDC could see the CNA from the far side of the bed upon entry, so the curtain wasn't pulled far enough. Interview with the SDC, on 02/04/16 at 10:45 AM, revealed the facility CNA's were trained to protect the privacy of all residents. They viewed a video and received didactic instructions regarding privacy with their general orientation. Each CNA also received continuing education for privacy annually. CNAs were taught whenever a resident was undressed that the resident blinds and room door were to be closed and the privacy curtain completely pulled around the bed. She also stated during any procedure that required resident nudity was the only area should be bare. Interview with the Director of Nursing (DON), on 02/04/16 at 2:13 PM, revealed the facility nurses and CNA's had been trained on hire and yearly to ensure the privacy of all of the residents during personal care. She stated the Unit Nurse Manager and the Minimum Data Set (MDS) Nurse made rounds to monitor the care given to the residents and she had not been informed of any concerns regarding lack of privacy for the residents during personal care.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to maintain an effective system in place to ensure staff followed infection control practices for one (1) of sixteen (16) sampled residents (Resident #4). Certified Nurse Aide (CNA) #8 faled to remove her soiled gloves and touched Resident #4's skin, clothes, linens, heel protectors, call light, and bed control while performing perineal care. The findings include: The facility did not provide a policy on handwashing or changing gloves. Review of the facility's policy regarding the Infection Control Program, dated September 2014, revealed the infection control program was designed to establish and maintain an effective program which provided a safe, sanitary, and comfortable environment and attempted to prevent the development and transmission of disease and infection. Review of Mosby's Six (6th) Edition, Giving Female Perineal Care, the facility's standard of practice guideline, not dated, revealed staff should perform hand hygiene, put on gloves, separate the labia, clean downward from front to back, pat the area dry, and then remove and discard gloves. Review of Resident #4's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as totally dependent on staff for hygiene performance. Observation of perineal care for Resident #4, at 1:05 PM on 02/04/16, revealed CNA's #8 and #9 performed hand hygiene and put on disposable gloves. CNA #9 turned Resident #4 on his/her right side, while CNA #8 wiped the perineal area from front to back. CNA #9 turned Resident #4 on his/her left side while CNA #8 wiped the resident from front to back. CNA #8 kept on the same soiled gloves and placed a clean brief on Resident #4. CNA #8 adjusted Resident #4's clothing, touched his/her legs, placed heel protectors on the resident, touched Resident #4's linens, positioned Resident #4's arms and hands, placed the call light next to Resident #4, and touched the bed control, all while wearing her soiled gloves. CNA #8 then removed her gloves and performed hand hygiene. Interview with CNA #9, on 02/04/16 at 1:10 PM, revealed she was trained to change gloves between tasks. CNA #9 stated CNA #8's gloves were dirty after CNA #8 performed perineal care and everything CNA #8 touched with her gloves was dirty and could make Resident #4 sick. Interview with CNA #8, on 02/04/16 at 1:12 PM, revealed she did not change gloves after providing perineal care for Resident #4 but she knew she should have. Her gloves were dirty and she contaminated everything she touched with the dirty gloves. Interview with the Unit Manager, at 1:25 PM on 02/04/16, revealed staff did not perform proper perineal care for Resident #4. The entire area was contaminated when staff did not remove gloves after perineal care. Interview with the Director of Nursing (DON), on 02/04/16 at 2:00 PM, revealed CNAs were inserviced at least quarterly on proper infection control practices. In addition, staff were trained to remove gloves and perform hand hygiene after perineal care. She as well as the Quality Improvement Coordinator (QIC) completed monthly audits in which they observed staff performing perineal care on residents. The DON, stated she had not identified any issues with improper perineal care. Interview with the QIC, at 2:20 PM on 02/04/16, revealed she completed monthly audits of hygiene and grooming. The QI Coordinator stated she observed five (5) to ten (10) staff per month completing care, including perineal care, for residents to ensure care was appropriate. The QI Coordinator stated she had not identified any issues with improper glove change. The QIC stated staff failing to remove gloves after Resident #4's perineal care was an infection control concern.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure food was stored under sanitary conditions. Five (5) food products stored in Side By Side Freezer #2 were not labeled with the opened date. One (1) of the five food products in Freezer #2 was not sealed properly and left open to air. The findings included: Review of the facility's policy titled, Purchasing and Storage, dated August 2013, revealed food and stock items were to be dated and rotated. The policy did not mention proper procedures for storage of frozen items concerning labeling with opened dates and sealing opened items from air. Observation of the side by side freezer #2, on 10/22/13 at 8:30 AM, during the initial kitchen tour, revealed one (1) package of frozen Fujita chicken, one (1) package of frozen biscuits, one (1) package of frozen tater tots, and one (1) package of dinner rolls were opened and not labeled with the opened date. Another package of frozen Fujita chicken was observed opened, not labeled with the opened date or sealed to air. Interview with the Dietary Manager (DM), on 10/22/13 at 9:00 AM, revealed she was new in her position and had only worked at the facility for two months. The DM revealed there was no way to know how long these food items had been opened. The items not labeled with open dates and the item opened to air could become stale, taste badly, or become contaminated.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to maintain an error rate of less than five (5) percent (%) during a medication pass. There were five (5) errors out of twenty-seven (27) opportunities, resulting in a 18.52% medication error rate for four (4) of seventeen (17) sampled and five (5) unsampled residents, Unsampled Residents A, B, C and D had errors during their medication administration. The findings include: Review of the facility's policy regarding The Administration of Eye Drops, undated, revealed the goal was to introduce liquid medication into the eye in an accurate and safe manner to cause the resident the least amount of apprehension and discomfort to the sensitive tissues of the eye, particularly to the cornea. The staff was to pull down the lower eyelid with the index or middle finger, creating a pouch and instruct the resident to look up. Steady the hand by placing it against the resident's forehead and place the prescribed number of drops of medication inside the lower eyelid close to the outer corner of the eye. Never drop medication directly on the sensitive cornea of the eye. Review of the facility's policy regarding the Receipt of physician's orders [REDACTED].[REDACTED] Review of the facility's policy regarding the Administration of Oral Medication Through a Gastrostomy Tube, undated, revealed an irrigation of the [DEVICE] with thirty milliliters (30 ml) of water would be administered to reduce the risk of clogging the tube. 1. Observation in the hallway, on 10/23/13 at 8:24 AM, revealed Licensed Practical Nurse (LPN) #1, asked Unsampled Resident B, if they were back from breakfast and ready for their medications? Unsampled Resident B, nodded yes, and said, okay. LPN #1 was observed to administer [MEDICATION NAME] capsule forty (40) milligram (mg), one (1) by mouth. Review of the physician's orders [REDACTED]. His/Her physician orders [REDACTED]. 2. Observation, on 10/23/13 at 8:24 AM, revealed LPN #1 instilled one (1) drop on the cornea in both eyes of Unsampled Resident B as the resident squinted each eye with each drop. Review of the physician orders [REDACTED]. 3. Observation, on 10/23/13 at 8:35 AM, revealed LPN #1 instilled [MEDICATION NAME] Solution 0.1%, one (1) drop in each eye on the cornea in Unsampled Resident B's eyes. The resident squinted each eye with each drop instilled. Review of the physician's orders [REDACTED]. Interview, on 10/23/13 at 8:45 AM, with LPN #1 revealed she had been trained on how to instill eye drops. She stated, the resident was difficult to put the eye drops in because he/she did not hold their eyes open. She reported, she had been in-serviced on how to administer medications. 4. Observation, on 10/23/13 at 8:51 AM, revealed LPN #2 administered [MEDICATION NAME] DM, five (5) milliliters (ml) by mouth to Unsampled Resident C. Review of the physician orders [REDACTED]. Interview, with LPN #2, on 10/23/13 at 1:20 PM, revealed she had received training on medication pass and also had attended in-services at the facility. She reviewed the physician orders [REDACTED].[REDACTED]. She stated, the staff reviewed the new orders on the night shift. 5. Observation of the medication pass for Unsampled Resident D, on 10/23/13 at 11:55 AM, revealed LPN #1 administered crushed medications via [DEVICE] without a flush, followed by Vitamin C liquid via [DEVICE]. LPN #1 continued to administer [MEDICATION NAME] liquid, [MEDICATION NAME] liquid without water flushes between each medication administered via the [DEVICE]. Interview, on 10/23/13 at 6:07 PM, with LPN #1 revealed she was trained on medication administration with [DEVICE]s. She stated, she should have flushed the [DEVICE] with water between each medication. Review of the in-service training reports with staff attendance, dated 06/13/13 at 1:00 PM, revealed subjects covered, included medication pass and documentation. LPN #2 signed the in-service attendance record. Record review of the in-services training report with staff attendance, dated 06/27/13 at 1:00 PM, revealed subjects covered, included medication pass and documentation. LPN #1 signed the in-service attendance record. Interview, on 10/24/13 at 2:27 PM, with the Director of Nurses (DON) revealed the night shift verifies the physician orders [REDACTED]. She revealed the staff had been in-serviced on medication administration. The DON further stated the nursing staff should have flushed the [DEVICE] between medications and eye drops should have been administered correctly.